Cervical cancer is one of the few malignancies that can be prevented through screening. In this presentation you will learn about established and new methods of screening. Screening has saved hundreds of thousands of American lives. Every woman listening to this presentation should get regular cervical cancer screening—[meaning that they should have regular Pap tests and HPV tests when recommended by a healthcare provider.] This is a preventable cancer!
Cancer still drastically changes the lives of many women in the U.S., but with the empowerment through knowledge, more women are participating in prevention and screening activities that are reducing the risk of dying of these diseases. Cervical cancer rates are still far higher than they should be since over half of the women with this diagnosis have not had a Pap test in over three years. This educational material is designed to improve participation in screening practices through a better understanding of benefits.
Where Pap tests are not available for screening, cervical cancer is the number one cancer killer of women. Cervical cancer typically affects women at younger ages than other gynecologic cancers. That’s why we [especially??] urge all reproductive-age women to educate themselves and to participate in screening. [MARK—are Pap tests recommended for women until age 70?] The Pap test has reduced the risk of cancer by early detection of cells destined to become cancer.
The vulva is the female external genitalia, just outside the vagina. The vagina is located between the vulva and the bottom of the womb (the cervix). The cervix is responsible for keeping babies inside the womb until the baby is mature enough for delivery. The uterus is where the fertilized eggs implant and it houses babies for nine months. It is also responsible for menstrual cramps through its muscular contractions. The fallopian tubes transport eggs and sperm. The ovary is responsible for monthly production of eggs [in reproductive age women] as well as for hormone production. Because there are often no symptoms with early cervical cancer and a woman cannot see her own cervix, regular cancer screening examinations are important to find early changes.
The cervix is the communication between the vagina and the uterus that keeps babies inside until their due date and provides transport for sperm to get to the uterus. The cells on the outside of the cervix are squamous mucosa, like the vagina and the inside of your mouth. The cells on the inside of the cervix are glandular and are responsible for the production of mucous, like the inside of your nose. Cervical cancers tend to occur where the two cell types meet; we call this the transformation zone. Cancers can come from the squamous or the glandular cells. The glandular cancers hide deeper in the cervix and are harder to detect.
Most women who have cervical cancer have not had Pap tests regularly. About 75% of U.S. women had a Pap test in the past three years. Cervical cancer is uncommon in this group of screened women. Abnormal results of the Pap test are common and do not always mean precancer. Women should talk with their health care provider about any abnormal results. Do not be afraid. Effective treatment is available if needed.
The cause of cervical cancer is a sexually transmitted virus, called the human papillomavirus. There are many HPV types and only some cause cancer. HPV infections (even high-risk types) usually go away without treatment. Low-risk HPV types can cause genital warts. It is the high-risk types cause most abnormal pap tests, precancer and cancer of the cervix, vagina and vulva.
Most men and women who have HPV never know they are infected. HPV can be detected by a DNA test. Women with infections that do not go away for years are at highest risk of precancer and cancer. HPV testing is relatively new, and many women will first hear about this virus when they have an abnormal Pap test or a positive HPV test. If you don’t have HP, you are at low risk for developing cervical cancer. If you test positive for HPV, talk to your health care provider about the next steps. You are not alone. This is a very common infection.
This is a very common virus. Studies show that most sexually active women have had HPV at some time. In fact, HPV infection is so common in women ages 18-29, that current recommendations for screening advise against testing women in this age group.
Most women are at risk since sex is a normal adult activity. The more partners a woman has the greater her chances of being infected with HPV. Studies show that even women who report one lifetime sexual partner have about a 10% chance of having HPV infection. We really don’t know everything about how this virus is transmitted. [Mark, we say that it is sexually transmitted, so this seems a contradiction.]
The risk for cervical cancer increases with each additional factor listed. All of our bodies have the ability to fight infections. Some of our bodies are more effective fighters of HPV than others. A weakened immune system from any cause makes the body less able to fight the virus. Women who smoke are more likely to get cervical precancer and cancer. Tobacco may contribute to cervix cancer risk in multiple ways. First, tobacco decreases the bodies ability to fight off infections like HPV. Second, some of the [cancer-causing] chemicals found in tobacco are concentrated in the mucous made by the cervical glands. When a woman who smokes has an HPV infection, the carcinogens and the virus are a “double hit” for her cervix.
The longer you wait to have sex, the fewer partners you are likely to have, thus reducing your risk for cervical cancer. Your partner’s partners also can increase your risk. If you already smoke, talk to your health care provider about programs to help you stop. Good nutrition helps strengthen your immune system and allows the body to dilute the effects of cancer-causing agents. Some research suggests that adequate folic acid, found in foods such as uncooked spinach, romaine lettuce, rice, lentils and, believe or not, Cap’n Crunch, can reduce your risk of cervical cancer. Condoms do decrease the spread of HPV as well as other sexually transmitted diseases, so use them. Most importantly, if Pap tests are performed regularly, you will be identified as having a problem before it is life threatening, in most cases. Now, a new vaccine can additionally help protect you from developing cervical cancer. If your healthcare provider recommends it, get the cervical cancer vaccine. [Mark--why not say if you are between 9-26, get vaccinated. We have not applied the healthcare provider caveat elsewhere.}
When you have a Pap test, your healthcare provider scrapes cells from the cervix and places them on a microscope slide or into a jar containing liquid. Laboratory tests are run to find out if there are any abnormal cells. [Mark—do we need to mention here that liquid testing is more accurate??] If abnormalities are found, you will be notified to return for repeat testing. If precancer changes are found, they are easily treated, but follow-up is necessary. Unlike mammograms, chest X-rays and the PSA test for prostate cancer, Pap tests can detect changes before cancer develops.
Many women assume that if they have a pelvic examination, they also are getting a Pap test. This is not always the case. Ask you healthcare provider how often you should be tested given your age, medical and sexual history. Make a file and put all of your Pap tests results in it for future reference. This test is just a screening test for cervix cancer. It is not a good test for other types of cancer. There is currently no recommended test for uterine or ovarian cancer, unless you have a strong family history of cancers. If you want more information about other cancers, go to www.wcn.org. January is Cervical Cancer Screening Month. It is a good time to schedule your annual exam.
Current knowledge suggests it takes at least three years for cervical cancer to develop. Since cervical cancer is sexually transmitted, you should have your first Pap test three years after you have sex or when you are 21, whichever comes first.
The American Cancer Society recommends annual Pap tests until age 30. If the new liquid-based test is used, you can be screened every two years. Women 30 and older may be screened every two to three years if you have three normal tests in a row. If the new combination HPV and Pap test is used, you can wait three years between Pap tests [if your results are normal.]
The purpose of the Pap test is to find problems before symptoms occur. Once symptoms occur, the success rate for treatment goes down. It is possible to prevent cervical cancer because precancers can be detected with Pap tests and treatment can be started.
New testing options are making Pap test more accurate. However, it is still possible for an abnormality to be missed. Repeat testing improves the odds of finding any abnormalities. It is possible to have your first Pap test abnormality many years after you had sex with an infected partner. Realize also that a woman’s risk can change. You may have a new sexual partner or your partner may have a new partner.
A routine Pap test should be performed between periods. If you are having abnormal bleeding, make an appointment as soon as possible. Keep your appointment because the bleeding may be a sign of cancer.
Like any new experience, you may wonder what will happen during your first Pap test. If you have concerns during the test, tell your healthcare provider. Even if you find a Pap test embarrassing or mildly uncomfortable, it is worth it.
You can feel in control of your health by taking responsibility for knowing the results of all of your tests. Be sure you receive your results. Do not assume that a lack of a letter or phone call, means everything is ok. If you have not received your results in a reasonable amount of time, call your provider’s office. Remember that you know your body best. If something doesn’t seem right, even if you have had a normal Pap test, make an appointment with your healthcare provider.
The American Cancer Society recommends that you have a Pap test four to six months after your hysterectomy if your surgery was done for moderate to severe dysplasia or cancer. If you have three normal Pap tests in a row following your hysterectomy, you may discontinue Pap tests. If you had a hysterectomy, and did not have a previous cancer or precancer, you are at very low risk. A Pap test is not recommended, but other preventive health care is still important.
If you are 70 or older with a history of normal results, you are at very low risk of cervical cancer and do not need Pap test. If you have sex with a new partner, this may change your risk. Talk to your healthcare provider about if and when you need a Pap test.
Women who are younger may have the liquid-based Pap test, which only needs to be repeated every two years. The Pap test also might be sent to a computer for confirmation of a negative result. [Mark—why are we saying only younger—do we mean only women who still have periods??] If you are 30 or over, it may be useful to combine the HPV DNA test Mark—do we need to say DNA test here?]with a Pap test. It tells you if the cells look normal and if high-risk HPV DNA [ditto] is present. The combination of these tests only needs to be repeated every three years if both tests are negative [or normal?]. Sometimes, the Pap test is now read by new computer reviews. This technology is an added ‘safety-net’ for review of your Pap test. Not all providers offer Pap test imaging. You should talk with your healthcare provider about these advances in cervical cancer prevention. If you decide to have one of the new screening tests, you might want to make sure it will be covered by your insurance plan. Also, not all providers offer all the tests yet. Additionally, your provider may offer to include the cervical cancer vaccine, if you are eligible.
In the United States, approximately 50 million women undergo a Pap test each year. Of those, about 7-8% will have an abnormal result. This pyramid shows the break-down of Pap test abnormalities by frequency: About 2 million women have atypical squamous cells (ASC), 1.25 million have low-grade abnormalities (LSIL), about 300,000 have high-grade abnormalities (HSIL) and about 12,000 have cervical cancer each year. This pyramid also indicates the breakdown of abnormal Pap tests by by their proximity to normal or cancer. The higher up you go, the worse the abnormality. Fortunately, the most common abnormal findings on a Pap are minimally abnormal changes or low-grade abnormalities with the high-grade pre-cancer or cancer changes being much less frequent. [Mark—I assume these numbers are still accurate?]
An HPV test is sometimes useful to determine if you need any further evaluation. This is particularly true for the minimally abnormal Pap tests with atypical squamous cells of undetermined significance, often abbreviated as ASC-US. The HPV test is collected just like a Pap test. In fact, if the Pap test is collected in a liquid, then the HPV test can be run on that liquid if the Pap test shows minimally abnormal results. The test checks for high-risk HPV. The FDA approved HPV DNA test (DNA with Pap [no longer used—just HPV test] can identify 13 different high-risk HPV types. About 90% of cervical cancers are caused by one of these 13 types.
There is a spectrum of Pap test results from “normal to “cancer or carcinoma.” In between normal and cancer, there is a range of abnormalities, such as ASC-US (the abbreviation for atypical squamous cells of undetermined significance) or LSIL (low-grade squamous intraepithelial lesions) to more significant cellular changes, such as HSIL (high-grade squamous intraepithelial lesions), AGC (atypical glandular cells) or AIS (adenocarcinoma in situ). A Pap test is only a screening test. Additional tests are needed to determine if there is indeed a pre-cancer change or cancer. The abnormalities called ASC-US sometimes harbor pre-cancer changes, but most often reflect inflammation, hormonal changes or an infection with the human papillomavirus. If your Pap test shows ASC-US, any of the following three management options may be chosen as the next step by you and your doctor: HPV testing, repeat Pap tests at approximately six month intervals or immediate colposcopy. The other abnormalities are almost always caused by HPV. Thus, testing for HPV is not helpful in those cases. The more abnormal tests, such as HSIL, AGC, AIS, and cancer are also more worrisome for true pre-cancer or cancer changes. Any of these Pap test results should be followed by a colposcopy with biopsies. For AGC, an endometrial biopsy may be added. [If cancer is suspected or diagnosed, see a gynecologic oncologists. A gynecologic oncologist is a physician who specializes in the care of women with [reproductive cancers] precancers or cancers and would often be consulted if the Pap test shows AIS or cancer. [Mark—we are trying to say it this way, but am can use the previous language if you prefer.]
The first step in the evaluation of an abnormal Pap test is a colposcopy. Colposcopy is a test that helps find abnormal areas in the cervix. This is done in the doctor’s office. Similar to the examination for obtaining a Pap test, a speculum will be placed into the vagina. A nurse or doctor then applies a vinegar-like solution onto the cervix and examines the cervix with the colposcope, which is a magnifying lens with a strong light. If there are abnormal areas, a biopsy may be taken. [This implies that nurse do colposcopies—is this true?]
During a biopsy, a very small piece of tissue is removed so that a pathologist can evaluate it under a microscope to make a diagnosis. Any visible abnormality of the cervix should be biopsied to make sure of the diagnosis. Having a biopsy taken may cause some discomfort, like a menstrual cramp that lasts a few seconds. Sometimes, your doctor will also perform an endocervical curettage, in which a little bit of tissue will be scraped from the cervical canal in order to examine it more closely under the microscope. And, at times colposcopy with biopsies and endocervical curettage is not enough to find the explanation for the abnormal Pap test and to make sure of the diagnosis. In this situation, a conization is performed, during which a larger, cone-shaped piece of tissue is removed from the cervix.
The pathologist examines all tissues under the microscope. Similar to what was discussed earlier for the Pap test, biopsy results can show a broad spectrum with the two extremes being “normal” and “cancer or carcinoma”. In between, there is a range of abnormalities called CIN I to III. CIN stands for cervical intraepithelial neoplasia. CIN III is a pre-cancer change. This means the cells are highly abnormal, but do not yet invade or spread like cancer cells. It is important to understand that treatment depends on the biopsy results, NOT the Pap test. For CIN I management options include treatment or observation. Which route of management is right for you will depend on a number of factors. Observation is often preferred over immediate therapy since the chance that CIN I spontaneously regresses to normal is about 60%. However, about 10% will progress to more severe abnormalities. Therefore, a schedule of repeat examinations will be needed when CIN I is diagnosed, often Pap tests every six months. CIN II and III should always be treated. If any invasive cancer has been found, you should be seen by a gynecologic oncologist to determine what treatment you will need.
If you need treatment for CIN, there are multiple treatment options such as LEEP, laser, cryotherapy, and cone biopsy. Options can be divided into two main groups: those that remove the area of abnormality (LEEP, cone biopsy) and those that destroy the area of abnormality (cryotherapy, laser vaporization). Each of those have their indications, advantages and disadvantages, but, importantly, cure rates are comparable. In special circumstances, a hysterectomy may be recommended.
Cryotherapy, LEEP, laser and conization are similar in their ability to treat CIN. Estimated cure rates range from 73% to 90% with a single treatment. However, 10% to 27% of patients will have future problems with CIN, making close follow-up after treatment very important. Once a patient has been treated for CIN, her risk for developing invasive cervical cancer is about 1%. One major concern regarding treatment of cervical pre-cancers has been the potential that fertility may be decreased. Treatment of CIN could make it more difficulty to get pregnant or to carry the baby to full-term. This could happen because of cervical stenosis (scarring of the opening of the womb), decreasing cervical mucous formation or cervical incompetence (weakening of the cervix with difficulties of holding the baby inside the womb until term). It is important to notify your obstetrician regarding your history of cervical surgery if you have a future pregnancy.
You can feel in control of your health by taking responsibility for knowing the results of all of your tests. Be sure you receive your results. Do not assume that a lack of a letter or phone call, means everything is ok. Remember that you know your body best. If something doesn’t seem right, even if you have had a normal Pap test, make an appointment with your healthcare provider. Also- DO NOT SMOKE!
In June 2006, a new vaccine was approved by the US Food and Drug Administration (FDA). This vaccine can help prevent cervical cancer by providing protecting you from the ‘high-risk’ HPV virus types that cause 70% of cervical cancer. This vaccine is approved for girls and women ages 9-26. The benefit of the vaccine declines with increasing HPV exposure.
Girls age 11 and 12 should routinely be vaccinated. Vaccination can be started as young as age 9. Girls age 13-18 should receive the vaccine if they have not already been vaccinated. Women ages 19-26 are eligible to receive the vaccine, but it may not work depending on your prior exposure to HPV. The vaccine will not protect everyone, so it is important to continue getting cervical cancer screening with a Pap test [and a HPV test when recommended by your healthcare provider.} The vaccine is not approved for women over 26 and men. [Mark, should we add the phrase “at present” to signal that this may change?]
If you started having sex, the vaccine benefit may be lower for you. Also, the vaccine has limited benefit if you are already infected with HPV. Early vaccination, regular Pap tests and HPV tests when recommended by a healthcare provider will provide you with your best protection against cervical cancer.
Getting the vaccine is easy. You will have a shot followed by another 2 months later and another 4 months after that. Sometimes it may hurt for a few days after the shot. If you are pregnant or trying to get pregnant, do not get the vaccine.
Usually women with cervical cancer have no symptoms, particularly if the cancer is small. The common symptoms of cervical cancer are: Bleeding between periods Bleeding or spotting after sexual intercourse Bleeding or spotting in women who have already gone through menopause Unusual, continuous, foul-smelling vaginal discharge In women with more advanced cervical cancer additional symptoms may occur, such as: Progressive and ultimately constant pelvic pain One-sided leg pain caused by nerve involvement A pelvic mass Bleeding from the bladder or rectum. It is not unusual for a woman with cervical cancer to have no symptoms.
Often times cervical cancer is first diagnosed by a primary care provider. Once the diagnosis is suspected or confirmed, the primary care provider will help find a gynecologic oncologist. These physicians are expert in the diagnosis and treatment of cervical cancer. Women with cervical cancer are encouraged ask about clinical trials. Co-operative group trials are performed at many institutions around the country and your gynecologic oncologist can suggest appropriate trials. [Woman also can log onto the Women’s Cancer Network (www.wcn.org) to review the clinical trials section for available clinical trials.] Radical hysterectomy and chemoradiation are the most common treatments for cervical cancer. Even with a diagnosis of cervical cancer, a woman may have the option of preserving her ability to have children and to keep her ovaries.
There are many treatment options for cervical cancer. It all depends on how big it is, your medical history and your concerns for future fertility. You should discuss your treatment options with a gynecologic oncologist.
The clinical stage is the extent of cancer at the time of diagnosis. Staging is necessary so that physicians can accurately communicate with each other about the disease. This allows doctors to discuss treatment options, to consider enrollment in clinical trials and to compare the outcomes in efforts to improve quality of care. Clinical staging [should be performed by a gynecologic oncologist and] is completed before treatment begins. Cervical cancer can be broken into 4 general groups. Stage I Stage IA cancers are cancers with minimal invasion that can only be detected microscopically. Stage IB cancers are those that involve only the cervix. The cancers that are larger than 4 cm are classified as stage IB2. Stage II A stage IIA cervix cancer indicates that there has been spread of the cancer to involve both the cervix and upper portion of the vagina. A cancer is defined as stage IIB if there is extension of the cancer into the tissue next to the cervix. Stage III A stage IIIA cervical cancer has involvement of the lower vagina and a IIIB has extension of the cancer towards the pelvic sidewall. Stage IV Stage IV cancers involve the bladder, rectum, lungs or other organs.
A cervical conization is often used to diagnose or exclude the presence of a very small cervical cancer. This procedure is performed in the operating room with or without general anesthesia where a cone shaped segment of the cervix is removed. Alternatively, a large cervical excisional biopsy can be performed in the office under local anesthesia. The risks associated with a cervical conization are bleeding, infection and infertility.
If a hysterectomy must performed for the treatment of cervical cancer, a radical hysterectomy is usually performed. This involves removal of the uterus along with a portion of the surrounding support tissue and a portion of the upper vagina. The lymph nodes in the pelvis and sometimes those near the aorta are removed. The radical nature of the procedure results in a few more complications when compared to a simple hysterectomy. The most common changes are noted in the function of the bladder (you can’t tell when your bladder is full, so you must watch the clock to know when to go), shortening of the vagina and constipation. A radical hysterectomy does not require removal of the ovaries.
If you have an early cancer and you desire future fertility, a radical trachelectomy may be an option for you. The cervix and the surrounding tissues are removed without removing the uterus. So you still have a womb to carry a pregnancy. This treatment option may not be for you- discuss this with a [your] gynecologic oncologist.
For some women, treatment with chemoradiation is a better option than surgery. This is most often true with advanced cancer. Radiation is composed of two portions, external and internal radiation. A very low dose of chemotherapy is administered at the same time as the external radiation. This low dose of chemotherapy makes the radiation therapy more effective. External radiation is usually given in small doses five days a week for about five weeks. Fatigue, nausea, diarrhea, and skin or vaginal irritation are common side effects. For internal radiation, a radiation cylinder is placed inside the vagina where it delivers radiation treatment directly to the cervix. This procedure can last several hours to a full day in the hospital. Several treatments may be necessary.
The survival rate five years after diagnosis varies depending upon the stage of cervical cancer. The risk increases with higher stages of disease. However, there are treatment options for everyone.
[Be patient with yourself as you re-establish your wellness. This journey is different for each woman, but some women find strength from family and friends as well as support from others, including counseling. Exercise is good emotional therapy and good for the healing process. If you have any questions about what exercise is best for your, talk to your healthcare provider.]
The most important thing that any woman can do to prevent cervical cancer is to have a Pap test regularly! It is very important to educate our friends about the importance of a Pap test. There are many reasons women postpone having a Pap test. Help your friend by reassuring her that a Pap test does not hurt. Give her a ride to get the Pap test. Offer to help with child care. Help her identify a health care provider or clinic so that she can make an appointment for her Pap test.
Cervical Cancer Screening· Evaluation· Treatment
Evaluation · Treatment
About this Presentation
This presentation is intended to help
women take an active role in their health
care. It does not replace the judgment of
a health care professional in diagnosing
and treating disease.
GCF Mission Statement
The mission of the Gynecologic Cancer Foundation (GCF)
is to ensure public awareness of gynecologic cancer
prevention, early diagnosis and proper treatment. In
addition the Foundation supports research and training
related to gynecologic cancers. GCF advances this
mission by developing and implementing programs to
meet these goals. Programs and outreach efforts are
supported by public and private funding.
GCF gratefully acknowledges the National Cervical Cancer
Coalition (NCCC) for the initial funding that supported the
development of the original cervical cancer slide presentation.
Updated December 2006
Information Hotline: (800) 444-4441
A list of specially trained gynecologic
oncologists practicing in your local area is
available by visiting the Women’s Cancer
Network at www.wcn.org or by calling the
Free educational brochures on gynecologic
health are also available through the Women’s
Cancer Network at www.wcn.org
Women’s Cancer Network: www.wcn.org
and breast cancer risk
and colon cancers
Links to other sources
of cancer information
New cancer diagnoses in the U.S.
Uterus (womb) 41,200
Source: American Cancer Society.
What is cervical cancer?
It is a cancer of the female reproductive tract
It is the most common cause of cancer death
in the world where Pap tests are not available
It is the easiest gynecologic cancer to prevent
through screening and early vaccination
What is the female reproductive tract?
What is the cervix?
Opening of the uterus
(womb) into the vagina
Two cell types present
Cervical cancer tends to
occur where the two cell
Source: TAP Pharmaceuticals, “Female
How common is cervical cancer?
500,000 women worldwide are diagnosed with
cervical cancer annually
50-60 million women in the U.S. have a Pap test
3-5 million women in the U.S. have an
abnormal result – usually due to precancer
changes on the cervix
Approximately 9,500 new cervical cancers
diagnosed in the U.S. per year
Over 3,500 deaths from cervical cancer in the
U.S. per year
Most Cervical Cancer Can Be Prevented
What causes cervical cancer?
The central cause of cervical cancer is
human papillomavirus or HPV:
HPV is transmitted through sexual contact
The HPV detected today could have been
acquired years ago
There are many different types of HPV that
can infect the cervix, vagina and vulva
•‘Low-risk’ types may cause genital warts
•‘High-risk’ types may cause precancer
and cancer of the cervix
• Most women who are infected with HPV will
never have any symptoms
If I have HPV, does it mean I will get cancer?
In most cases HPV infection will go away
Only women with persistent HPV (where the
virus does not go away) are at risk for cervical
How common is HPV?
Most men and women who have had sex have
been exposed to HPV
More than 75% of sexually active women
have been exposed to HPV by age 18-22
Who is at risk?
Women who have ever had sex
Women who have had more than one partner
Women whose partner (s) has had more than
one sexual partner
Women who have had a sexually-transmitted
Who is at risk?
Women who do not have Pap tests
Women with immune problems including those
Use steroid medications on a regular basis
Have organ transplant
Are undergoing chemotherapy
Are infected with HIV
Women who smoke-smoking all by itself
increases the risk of HPV infection and cervical
precancer lesions, and doubles the risk of
getting cervical cancer
How do I lower my risk?
Delay onset of sexual activity or remain
Know your sexual partner
Do not smoke
Maintain a healthy diet and lifestyle
Practice safe sex. Condoms decrease the
chance of HPV exposure.
If eligible, consider getting the vaccine that
prevents most cervical cancers.
Get your Pap test and HPV testing as
recommended by your health care provider.
What is a Pap test?
A test which collects cells from the surface of
the cervix and looks for any abnormal cells
Abnormal cells can be treated before cervical
When cancer is detected early, it is easier
What a Pap test is NOT!
A pelvic exam (You can have a pelvic
examination without a Pap test!)
A test for ovarian or uterine cancer
When do I need my first Pap test?
Three years after the onset of sexual
No later than age 21
How often do I need a Pap test?
Every year until age 30
After age 30, if you have only had normal
results and negative HPV testing, you may
have them every 2 to 3 years after discussion
with your physician and evaluation of your risk
I feel fine, so why do I need a Pap test?
A Pap test can find treatable changes of the
cervix (precancer) before you have a
symptom or notice a problem
Once a problem is symptomatic, it is harder
Why do I need to keep getting tested?
The test is not perfect
Changes (abnormalities) may occur since the
It may take many years for changes to
develop or be detected
Your risk changes if you have new partners
What is the best time to have a Pap test?
Schedule your Pap when you are not having a
It is best to abstain from intercourse, and avoid
use of tampons or douches for 2 days before
your Pap test
What should I expect when I have
a Pap test?
Feet are placed in stirrups (foot holders)
A speculum (thin duck-billed instrument made
of metal or plastic) is inserted into vagina to
see the cervix
You may have brief discomfort which is usually
You may have some spotting afterward
How do I find out about my Pap test results?
You may ask to have a copy mailed to you
You may call for your results. Be sure to know
If you have an abnormal result, it is extremely
important to follow-up for the recommended
Even after a normal Pap test, it is still important
to report any symptoms of abnormal vaginal
bleeding, discharge or pain to your doctor,
and call to be seen right away
Do I need a Pap test if I had a hysterectomy?
If you had a hysterectomy for a non-cancer
disease, you may not need a Pap test. This
needs to be discussed with your healthcare
If you had treatment for precancer or cancer
of the cervix, you may need a Pap test
If the cervix was left in place at the time of
your hysterectomy, you will still need Pap tests
Preventive health care is still important even if
you do not need a Pap test
Is there an age when I can stop having
The American Cancer Society recommends
that screening stop at age 70 if three or more
recent tests are normal, and there have been
no abnormal results in the last 10 years.
What is new in screening and prevention?
Liquid cytology-thin layer cytology. This is
where your cervical swab is placed in a
container instead of ‘smeared’ on a slide.
Combination of HPV test and Pap is now
available for screening women 30 years of
age and older. This helps identify patients at
increased risk for developing cervical cancer.
Pap test imaging by computer reviews in
addition to a review by trained personnel.
Vaccines for cervical cancer
Evaluation of the Abnormal Pap Test
and Treatment of Precancer
Abnormal Pap test – How common is it?
300,000 HSIL (High-Grade
1.25 million LSIL (Low-Grade
2-3 million ASC (Atypical
50-60 million women screened
What is an HPV test?
A test sometimes used to determine if you
need further evaluation
Cells are collected just like a Pap test
It checks for high-risk HPV
What happens if I have an abnormal
Depending on your Pap test result your
provider may advise one or more of the
Possibly an endometrial biopsy
Possible referral to gynecologic oncologist
What is a colposcopy?
Use of a magnifying
Application of a
onto the cervix
that can’t be seen
with the naked eye
Feels like getting a
Pap test, but takes a
Source: This is a copyrighted image of the California
Family Health Council, Inc. and may not be
reproduced in any way without the expressed written
permission of the California Family Health Council.
California Department of Health Services "What You
Should Know if your Pap Test is Abnormal"- Your
Colposcopy Exam, Donna Bell Sanders (Education
Programs Associates 1995; Campbell, CA).
What is a cervical biopsy?
Removal of a small
piece of tissue from the
May feel like getting a
Pap test or like a
menstrual cramp that
lasts a few seconds Source: TAP Pharmaceuticals,
“Female Reproductive Systems.”
Source: A. DeCherney and M. Pernoll,
Current Obstetric and Gynecologic
Diagnosis and Treatment (The
McGraw-Hill Companies, Inc.) 586.
What does the biopsy result mean?
Mildly abnormal (CIN I)
Usually you will be watched closely to see if
your body can fight the infection
More abnormal (CIN II)
Usually you will be scheduled for treatment
or watched closely
Precancer (CIN III)
Usually requires office or outpatient
Usually followed by a consultation with a
What are the treatment options for CIN?
There are a variety of effective options
for treatment. Most are outpatient or
office treatments. Treatment names that
you might hear include:
Rarely, a hysterectomy may be recommended
What can I expect after treatment for CIN?
Estimates of cure range from 73-90% with a
The risk for invasive cancer following treatment
is about 1%
Therefore, you still need to have regular Pap
Minimal impact on fertility
May impact on your ability to carry a child in
the future. You should discuss this risk with
your healthcare provider.
What you can do?
Take Control - Protect Yourself
1) Ask your doctor about an appropriate Pap test
screening interval for you
2) Make sure that you get a Pap test at the
3) Find out how and when you will learn about
the results of your Pap test
4) Follow-up! Don’t assume that no news is
5) Do not smoke
What is the cervical cancer vaccine?
The cervical cancer vaccine (also known as
the Human Papillomavirus or HPV vaccine) will
help prevent cervical cancer by providing
protection from the ‘high-risk’ HPV virus types
that cause 70% of cervical cancer
You can significantly decrease your chances
of getting cervical cancer if you get the
vaccine before initial sexual contact
The benefit of the vaccine declines with
increased HPV exposure
Recommended age groups of the cervical
Eligible for the
age group to
Eligible to receive
the vaccine, if not
Eligible for the
vaccine, if not
Not FDA approved
*The effectiveness of vaccine may be reduced
in this age group. The vaccine is less
effective with more prior HPV exposure.
Is the cervical cancer vaccine right for me?
If you are a female between the ages of 11 and 12 the
vaccine has proven benefit for you
If you started having sex, you can still get the vaccine,
but the benefit from the vaccine may be lower because
you may have already been exposed to HPV
The vaccine does not work to eliminate current HPV
The vaccine only prevents certain types of HPV infection
Early vaccination, regular Pap tests and HPV tests when
recommended by a healthcare provider will provide
you with your best protection against cervical cancer
What should I expect at my vaccine
You will need a series of three appointments
over 6 months
You will receive a shot, usually in the upper
arm, at each of the three appointments
Common side effects include:
A sore arm for a day or two after the
A headache and/or a low grade fever
You can use over the counter pain and fever
medications if needed
You should not get the vaccine if you are
pregnant or trying to get pregnant
What are the symptoms of cervical cancer?
Unusual vaginal discharge
Bleeding from the rectum or bladder
Some women have no symptoms
What should I do if I have just been
diagnosed with cervical cancer?
Find a gynecologic oncologist
Call 1-800-444-4441or visit the Women’s
Cancer Network “find-a-doctor” section at
Gynecologic oncologist is specially trained in
the comprehensive surgical care and medical
treatment of female reproductive cancers; a
gynecologic oncologist can manage your
care from diagnosis through completion of
treatment and follow-up care.
What should I do if I have just been
diagnosed with cervical cancer?
Discuss treatment options
Radiation with chemotherapy
Ask about clinical trials (Gynecologic
Preserve your fertility
Preserve your ovaries
Clinical staging of cervical cancer
Source: “FIGO Annual Report on The Results of Treatment in
Gynaecological Cancer” Journal of Epidemiology and
Biostatistics, (2001) vol. 6 no. 1, page 14.
What is a cervical conization?
• Removes a cone-
shaped piece of
• Often allows for
• Performed with
in the office or
anesthesia in the
Source: TAP Pharmaceuticals,
“Female Reproductive Systems.”
What is a radical hysterectomy?
Treatment option for early stage cancer
Not the same as the usual hysterectomy
Surgical removal of the uterus, cervix and
upper vagina with the surrounding tissues
Lymph nodes are removed
Removal of the ovaries is not required
What is a radical trachelectomy?
A possible treatment option for certain types of
early stage cancer
Surgical removal of the cervix and upper
vagina with the surrounding tissues. The
uterine body (womb) remains inside you.
Lymph nodes are removed
Removal of the ovaries is not required
Not an appropriate treatment option for
everyone with early stage cervical cancer
What is radiation with
Standard of care for advanced cancer
1. External radiation
2. Internal radiation
3. Low dose chemotherapy given at the
Cervical cancer: What is the chance of
survival after treatment?
FIGO Stage 5-Year Survival
Stage I 81-96%
Stage II 65-87%
Stage III 35-50%
Stage IVA 15-20%
Restoring wellness is a gradual process
Some women find strength from:
Friends and family
The challenges and the journey are different
for each woman with cervical cancer
How do I get my friend to have a Pap test?
Tell her it doesn’t hurt
Offer her a ride
Offer help with child care
Help her get an appointment
Help her find the right health care provider
Empower her with information: Tell your friend
about the importance of health prevention
GCF Supporting Organizations
This educational effort was undertaken by the Gynecologic
Cancer Foundation with initial support from the National
Cervical Cancer Coalition (NCCC). GCF gratefully
acknowledges and thanks NCCC for its efforts related to
cervical cancer public outreach.
For more information:
National Cervical Cancer Coalition
16501 Sherman Way
Van Nuys, CA 91406
Toll Free Hotline (800) 685-5531
Phone: (818) 909-3849
Fax: (818) 780-8199
Web site: www.nccc-online.org
GCF Supporting Organizations
GCF is the lead partner of the National Cervical Cancer Public Education
Campaign consisting of 31 other national partners committed to preventing
cervical cancer through early vaccination, regular Pap tests and HPV tests when
recommended by a healthcare provider.
For more information:
The Gynecologic Cancer Foundation
230 W. Monroe, Suite 2528
Chicago, IL 60606
Toll-Free Hotline (800) 444-4441
Phone: (312) 578-1439
FAX: (312) 578-9769
Web sites: www.cervicalcancercampaign.org
(Women’s Cancer Network)
Patient education programs of the National Cervical Cancer Public Education
Campaign are supported in part through unrestricted educational grants from
Cytyc LP Corporation, GlaxoSmithKline and Merck & Co., Inc.
Gynecologic Cancer Foundation
230 W. Monroe
Chicago, IL 60606